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Dysfunctional Uterine Bleeding

Dysfunctional Uterine Bleeding was found in 5-Minute Clinical Consult which helps you diagnose, treat, and follow up on over 900 medical conditions seen in everyday practice.

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Basics

Description

  • Dysfunctional uterine bleeding (DUB) is irregular menstrual bleeding (usually heavy, prolonged, or frequent); it is a diagnosis of exclusion after establishment of normal anatomy and the absence of other medical illnesses.
  • Commonly associated with anovulation

Epidemiology

Adolescent and perimenopausal women are affected most often.

Incidence
5% of reproductive age women will see a doctor in any given year for DUB.

Prevalence
10–30% of reproductive age women have DUB.

Etiology and Pathophysiology

  • Anovulation accounts for 90% of DUB:
    • Loss of cyclic endometrial stimulation
    • Elevated estrogen levels stimulate endometrial growth.
    • No organized progesterone withdrawal bleed
    • Endometrium eventually outgrows blood supply, breaks down, and sloughs from uterus.
  • Adolescent DUB is usually due to an immature hypothalamic-pituitary-ovarian (HPO) axis that leads to anovulatory cycles.
  • DUB can be broadly divided into anovulatory bleeding (usually irregular and unpredictable menses) or ovulatory bleeding (usually heavy regular menses) after pathologic causes of abnormal bleeding have been ruled out:
    • Pregnancy: Ectopic pregnancy, threatened or incomplete abortion, or hydatidiform mole
    • Reproductive pathology and structural disorders:
      • Uterus: Leiomyomas, endometritis, hyperplasia, polyps, trauma
      • Adnexa: Salpingitis, functional ovarian cysts
      • Cervix: Cervicitis, polyps, STIs, trauma
      • Vagina: Trauma, foreign body
      • Vulva: Lichen sclerosis, STIs
  • Malignancy of the vagina, cervix, uterus, and ovaries
  • Systemic diseases:
    • Inflammatory bowel disease
    • Hematologic disorders (e.g., Von Willebrand disease, thrombocytopenia)
    • Advanced or fulminant liver disease
    • Chronic renal disease
  • Diseases causing anovulation:
    • Hyperthyroidism/Hypothyroidism
    • Adrenal disorders
    • Pituitary disease (prolactinoma)
    • Polycystic ovarian syndrome (PCOS)
    • Eating disorders
  • Medications (iatrogenic causes):
    • Anticoagulants
    • Steroids
    • Tamoxifen
    • Hormonal medications: Intrauterine devices
    • SSRIs
    • Antipsychotic medications
  • Other causes of abnormal uterine bleeding:
    • Excessive weight gain
    • Increased exercise
    • Stress

Genetics
Unclear, but can include inherited disorders of hemostasis

Risk Factors

Risk factors for endometrial cancer (which can cause DUB):

  • Age >40
  • Obesity
  • Diabetes mellitus
  • Nulliparity
  • Early menarche or late menopause (>55 years)
  • Hypertension
  • Chronic anovulation or infertility
  • Unopposed estrogen therapy
  • History of breast cancer or endometrial hyperplasia
  • Tamoxifen use
  • Family history: Gynecologic, breast, or colon cancer

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